Jan 17, 2013

Teams
using checklists were 74 percent less likely to miss key life-saving steps in
care during emergency situations than those working from memory alone.

Boston - In an airplane crisis-an engine failure, a fire-pilots pull out a
checklist to help with their decision-making. But in an operating room
crisis-massive bleeding, a patient's heart stops-surgical teams don't. Given the complexity of judgment and
circumstances, standard practice is for teams to use memory alone. In a new study published in the January 17 issue
of the New
England Journal of Medicine, however,
researchers at Ariadne Labs,
a joint center for health system innovation at Brigham and Women's Hospital
and Harvard School of
Public Health, have found that teams using checklists
have markedly better safety performance. Specifically, the research shows that
clinicians provided with checklists in a novel study using advanced simulation of
surgical crises were three-fourths less likely to miss key life-saving steps in
care.

With many
surgical procedures happening simultaneously and around the clock in a hospital
setting, crises in operating rooms occur frequently, however, for individual
clinicians, these incidents are rare. These high-risk, stressful events require rapid, coordinated
care, and failure to rescue surgical patients who have life-threatening
complications is the largest source of differences in rates of surgical death
between hospitals. Researchers
report that the failure rate for performing life-saving
processes of care dropped from 23 percent to 6 percent during simulations when
checklists were available.

"For
decades, we in surgery have believed that surgical crisis situations are too
complex for simple checklists to be helpful. This work shows that
assumption is wrong." said Atul Gawande, MD, MPH, senior author of the paper, a
surgeon at BWH, professor in Health Policy and Management at HSPH, and director
of Ariadne Labs. "Four years ago, we showed that completing a
routine checklist before surgery can substantially reduce the likelihood of a
major complication. This new work shows that use of a set of carefully crafted checklists
during an operating room crisis also has the potential to markedly improve care
and safety."

For this work, researchers recruited 17 operating
room teams, comprised of anesthesia staff, operating room nurses, surgical
technologists, and a mock surgeon participant to participate in 106 simulated
surgical crisis scenarios in a simulated operating room at the STRATUS
Center for Medical Simulation at Brigham and Women's Hospital. Each team was randomized to manage half of
the scenarios with a set of crisis checklists and the remaining scenarios from
memory alone.

Researchers found that in addition to reporting
a reduction in the failure to adhere to life-saving processes of care during
simulations when checklists were available, 97 percent of participants indicated
that they would want these checklists used if they experienced an
intraoperative crisis as a patient

"Given these findings, Brigham
and Women's Hospital has now committed to implementing these checklists to
increase the safety of our patients and to evaluate the effect they have on care.
I would encourage other hospitals and surgical centers to consider doing the
same," Gawande said.

Researchers note that because
the study was performed in a simulated operating room, rather than in actual
operating rooms with real patients, it is unclear if adherence would improve in
a real world scenario. However,
high-fidelity simulation has become increasingly accepted in medicine as a
means of training and evaluation, and well-structured simulation testing has
been shown to efficiently assess the value of safety protocols in other fields.

This
research was funded by the Agency for Healthcare Research and Quality (AHRQ -
1R18 HS018537-01).